Has zirconia made a material difference in implant prosthodontics? A review
Introduction
The confluence between the digital revolution and material science development has offered a potential solution to biological, esthetic and mechanical limitations reported with conventional titanium implant supported restorations. In the last generation, a heightened demand for metal-free restorations has amplified the search for a new implant and restorative material [1]. Data regarding lack of titanium implant biocompatibility [2] contributing to peri-implant disease and even toxicity [[3], [4], [5]] have been documented in the literature. Furthermore, titanium implants and abutments have esthetic drawbacks. Several investigators have revealed that technical complications are higher with implant metal ceramic single crowns and fixed dental prostheses [[6], [7], [8]] than their tooth-borne counterparts, due to 8.7 times lower tactile sensitivity [[9], [10], [11], [12]]. Fractures and accelerated wear have also plagued complete arch resin-metal implant supported restorations. These issues have prompted the development of a new implant and restorative material that is more biocompatible, durable and esthetic. Milled zirconia holds such a promise but an evidence-based review of its present clinical application is in order as a pro-innovation bias is not uncommon [13,14].
This paper presents an overview of published studies (last 12 years) concerning the use of zirconia in implant prosthodontics. This includes its use as a replacement material for titanium implants, titanium abutments, implant supported metal-ceramic restorations and complete arch resin-metal prostheses. The purpose of the review is to cull the best available data on the biological, mechanical and esthetic properties of zirconia while summarizing its merits and disadvantages when compared to traditional materials.
Section snippets
Methods
An extensive literature search was completed using the electronic databases of PubMed, Science Direct and Web of Science. The used keywords strings were: Zirconia AND implants. The following filters were applied: (1) time interval from 2007 to 2019, (2) Additional refined search within the results: complete arch restorations, language: English
Abstracts were analyzed and excluded if they were clinical studies of less than 1 year of follow-up or if they did not include survival and success data.
Zirconia implants
Titanium dental implants have been documented with high restorative survival rates of 97.2% after 5 years for single crowns, 93.1% after 5 years for implant fixed dental prostheses (FDP) [11] and 96.8% after 10 years for implants supporting FDPs in edentulous jaws [15]. However, a sobering statistic regarding subject-based peri-implant disease of 66.66% in a recent meta-analysis [16] has prompted investigations for a metal-free alternative that may be more biocompatible and osteoconductive, while
Zirconia abutments supported by titanium implants
Replacing a missing tooth in the anterior zone with an implant-supported restoration is demanding because of biological, mechanical and especially esthetic considerations [69]. The latter concerns have prompted the use of a replacement for titanium abutments to address the greyish coloration of the peri-implant mucosa. Zirconia has been the favored material because of better mechanical properties than other ceramics such as alumina [70]. Current design options include prefabricated abutments,
Zirconia restorations supported by titanium implants
Can implant supported zirconia restorations improve on metal ceramic restorations as far as esthetics and mechanical complications? Does it matter if the zirconia is monolithic or layered? Is the digital fabrication as accurate as the analogue one?
In a recent systematic review, implant supported bi-layered zirconia single crowns demonstrated superior esthetics to metal ceramic crowns [91]. The 5-year survival rate was 97.6% for zirconia-based restorations with no significant differences in
Zirconia complete-arch fixed implant prostheses supported by titanium implants
Complete arch fixed implant supported prostheses on the maxillary or mandibular arch have been widely used as a treatment modality for edentulism, with an implant survival rate well over 90% with up to 10 years follow-up [15,102]. Traditionally, fixed prostheses restoring the edentulous arch have been designed with a metal-acrylic prosthesis. However, a high percentage of prosthesis-related technical complications (acrylic veneer fracture, fracture and wear of the denture teeth, and fracture of
Final considerations
Digital workflows using all zirconia ceramic materials, have offered implant patients a metal-free restorative alternative, with potential for enhanced esthetics and time/cost efficiencies, while achieving comparative biocompatibility and mechanical properties. For zirconia implants, further design developments and documentation are needed to assure the clinician of long-term success of two-piece implants. While the one-piece system has enjoyed up to a 5-year high survival and success rate,
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